DOI: 10.5272/jimab.14-2-2008.

93
ISSN: 1312-773X (Online) Journal of IMAB - Annual Proceeding (Scientific Papers) 2008, vol. 14, issue 2

RECONSTRUCTION OF FRACTURED PERMA-

NENT INCISORS IN SCHOOLCHILDREN USING
COMPOSITE RESIN BUILD-UP (REVIEW)
Ani Belcheva
Department of Pediatric Dentistry, Faculty of Dental Medicine,
Medical University, Plovdiv, Bulgaria

SUMMARY: MATERIALS AND TECHNIQUES

Crown fractures represent the largest part of
traumatic injuries to the permanent teeth. They are relatively
common event among schoolchildren. They create serious
functional, esthetic and psychological problems for both
children and their parents. The front position of fractured
teeth gives precondition for easy notises which make
esthetics the most important factor. The clinicians should
deal well with all characteristics of color, shape and adhesive
protocol. Difficulties may occur because of the small
patients age, the right choice of treatment plan and its
fulfillment.
In this review are collected data for the method
composite resin build-up when restoring fractured incisors.
A different improvements and objections have been
discussed in order to achieve succession in the right
therapeutic approach.
Key words: composite resin, crown fractures,
permanent teeth
INTRODUCTION
Crown fractures of permanent teeth are common
pathology in school ages as nearly half of the children have
at least one traumatized tooth before leave school (2). One
of the serious challenges for the clinician is to restore
esthetics and function of the fractured tooth. This includes
reconstruction of its shape and size; achievement of
identical color with definite opacity and translucency;
creation of harmony in esthetics reproduction of
fluorescence and opalescence as characteristics of color.
(24).
These objectives are attainable and with predictable
results after development of contemporary adhesives,
composite resin materials in combination of appropriate
technique (22, 23, 24, 26).
Aim of this review article is to discuss all the aspects
of reconstructing fractured permanent incisors at
schoolchildren using composite resin build-up.
Many clinicians reconstruct fractured teeth by using
composite resin for it is the most popular method in practice
but when treating a child there are some factors to be
considered. It is important to note that pulp chamber in
children has bigger volume (1) and in a presence of fracture
is exposed a great number of open dentin tubules to the
oral environment. This creates possibility for pulp damages
(13). As it is well known children fracture most often their
teeth between ages 8 and 11 (19). It is important to consider
that at small children eruption has not fully finished, as well
as the completely teeth position (1). Another specific feature
is the fact that after the trauma teeth should be treated
minimal invasively with lower number manipulations to
prevent pulpal or periodontal damage (19).
In a study by Alonso and Balboa the authors propose
preformed acetate crowns, used for a matrix, and composite
resin to restore a vast fracture in the front part of 10 years
old child. After 8 years of follow-up the restoration remained
esthetic and functional (1). Achievement of optimal
esthetics in this case is more difficult but the method can
be successfully applied in incisors with large fractures (11).
Another author uses this method but only temporary for
retention of Ca hydroxide- cement on fractured upper central
incisor of 7-years old girl. In this case the acetate crown is
fixed with glass-ionomer cement (13).
In fractured childrens teeth covering the exposed
dentin with Ca hydroxide- cement is recommended in
extensive opening of dentin surface and increased
sensitivity of thermal stimulants (13, 19). In the next
appointment the teeth are reconstructed permanently with
composite resin (15). The authors propose manufacture of
a silicone impression from restored with wax plaster models.
This silicone matrix helps to restore a palatal wall on which
to stratify enamel and dental layers. The matrix diminishes
operative time, gives opportunity for modeling the occlusal
anatomy upon stable palatal base (15).
Adhesive preparation of the enamel surface is used
for retention of restorations by composite resin build up.
Tan and Tjan find significant influence of tooth preparation
upon the strength of composite resin restorations of

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fractured teeth. A 2 mm bevel provides significantly higher
strength compared with 1 mm bevel or without preparation
(20).
In some cases it is necessary to put dentin pits for
strengthening the mechanical retention. Usage of para pulpal
pins when reconstructing fractured childrens teeth should
be managed with care for the widely exposed dental pulp.
Their exact placement requires preciseness and sometimes
leads to compromise in the esthetics (13). Some authors pay
attention of the extra tension that pins make in the hard
dental tissues. As alternative they apply different adhesive
systems that provide enough strength and excellent
esthetics (9).
Zalkind and Heling (25) describe in 1992 .a method
for consecutive reconstruction of widely destructed
incisors. This technique includes alternation of dentin layers
that restore the missing part of the dentine and enamel
layers representing the enamel surface of the tooth. This
concept is grounded in the contemporary stratification
technique for adhesive esthetic restoration. Bichacho (3)
recommends direct intraoral application of stratification
technique with which achieves optical effects of intact teeth.
Vanini in one of his studies uses 5 type layers (opacer,
dentin, based enamels, saturated enamels and dyes), that
reproduces the five parameters of natural color saturation,
brightness, intensity, opalescence and characteristics (24).
According to Terry (22) the clinician possesses
knowledge to create more natural restorations when
understands the whole tooths morphology and takes the
intact tooth as starting point for morphologic thinking.
Combination of contemporary composite resin with
optimized particles and such morphological thinking allow
building of restorations in harmony with the whole dentition.
Terry demonstrates incremental composite resin restoration
of fractured teeth.
De Araujo et al. stand that contemporary adhesive
restorations give the opportunity to the clinician to offer
minimal invasive, functional and esthetic treatment of
patients with fractured incisor teeth. That is way the usage
of this method of restoring fractured teeth in children is
successful because of the spare approach to the hard
tissues (7).
Fahl takes into consideration the qualities of the
composite resin materials. He points the basic challenge
when restoring fractured teeth to choose resin that has
adequate strength but also to ensure optical features of
intact teeth in order to create functionally strong and
esthetically pleasant restorations. To achieve absolute
control upon the process of crown restoration of great
importance are resins features such as high plasticity, wide
range of shades, different opacities and translucencies, as
well as good polishing. (8)
Hybrid composite resins have been defined as a
golden standard for restorations in the front region (23).
94 http://www.journal-imab-bg.org
The hybrid composite resin exhibit superior tense strenght
and improved abration resistance as well as reduced
polimerization shrinkage. They exhibit greater fracture
resistance as a result of inclusion of heavy inorganic fillers
(22).
Optimization of composite resin particles size to a
great extent solves the problem for esthetic restoration. The
recent introduction of an optimized particle composite with
an average true size of 0,4 m (with 90 % of the particles
below 0,8 m) represents development for the ideal
composite material (22). The developed microhybrid
composites and nanocomposites provide natural color
shades in combination with mechanical strength and good
polishing (10,22). Davis appreciates highly and recommends
restoration of fractured teeth with nanocomposites (6).
COLOR DETERMINATION
Tooth color depends on dentin (21). The organic part
of dentin absorbs light with different wave length. Size and
orientation of dentin tubules also influence absorption (12).
This defines the difference in color shades between young
patients and adults.
In spite polychromatic characteristics of natural tooth
in many cases it is possible to use one composite color for
the whole restoration. Stratification of composite layers is
the key for esthetically successful restoration. Esthetic
dentistry requires detailed observation, patience and
pedantic application of the clinical protocol. The color
variations that usually can not be observed from a distance
are one of the greatest desires of children and their parents.
This becomes main objective and for the dentist when
restoring precisely fractured incisor teeth (8).
The clinician should determine the basic color (hue),
intensity of color or its saturation (chrome) and brightness
(value) of the restoring composite material according to the
natural tooths color. The shades of microfilled and
microhybrid composites may change after polymerization.
While microfilled become lighter (have higher value and
lower chrome), microhybrid resins become darker (lower
value and higher chrome). In most cases patients are not
satisfied with monochromatic restorations. That is the
reason De Araujo et al. (7) to propose for every clinician
initially to work out clinical protocol and chromatic card of
the restored tooth and to pay attention on the three-
dimensional aspects. The main colors (, , , D),
intensities (A1, A2, A3) and different opacities and
translucencies of the natural tooth should be registered on
this card. The incisal third is of great importance, concerning
size localization color and shape of translucent region as
well as the presence of opalescent halo in the incisal edge.
In children is specific presence of mamelons that should be
placed to resemble natural teeth. (22)
Thickness, hue, chroma and velue of the enamel
layers influence the final dentin color that gives the clinician
/ J of IMAB, 2008, vol. 14, issue 2 /
possibility to put and polymerized enamel layers over dentin
composite layers. Enamel translucence tends to increase
with time. That should be considered when choosing color
of the enamel. Thickness of the enamel layer should be
approximately 0,2 to 1,0 mm. Restoration of fractured incisor
needs technique of incremental layering with adding of
opacer and dyes to mask the dark color of oral cavity(16).
In spite the excellent esthetic results that provides,
restoration of crown fractures with composite resin material
after exact color determination can be very labor and time
consuming. Thats the reason some authors to present
different clinical protocols which will save time and assist
the clinicians (4,6,7,8,9,11,17,22).
PROGNOSES
Prognosis of class IV-composite restorations is
controversial question, refering stability and esthetics.
Robertson et al. (14) concluded that for aperiod of 15 years
19% of the restorations of fractured childrens teeth have
been rebuild 10 times, another 25% have been assessed as
unsatisfactory at the final exam. Authors point the most
probable reasons for failure of these restorations and refer
them to the used adhesive system. Some of them are bond
insufficiency, leading to fracture of the resin, lack of marginal
adaptation, marginal stain.
In a long lasting clinical trial Spinas (18) investigate
130 children aged 8 to 18 and follows up quality of restored
with composite resin fractured incisors. The author finds
need of intervention at 3-years old restorations from
polishing to repair. In the period 3-5 years all the restorations
need to be repaired. The results show that restorations have
been changed 3 or 4 times before the significant decrease
of tooths adhesive recourses. According to the author
composite resin restorations can not be long lasting. He
considers after finishing of childs development that
prosthetic restorations are obligatory therapeutic alternative.
Any failure of composite restorations can lead to
fulfillment of less conservative method like veneer
preparation or prosthetic restoration. The last generations
adhesive systems and the optimized composite resin
materials increase duration of the restorations. That is way
the technique for composite resin restoration of fractured
incisors is accessible and realizable in schoolchildren (4,5).
CONCLUSION
Elaboration of the dentin adhesive systems, enamel
acid etching and development of contemporary composite
resin materials give choice at reconstructing fractured
permanent teeth at children. Application of incremental
technique by enamel and dentin layering makes restoration
sufficiently saturated in the dentin and at the same time
translucent in the incisal edge. This method re-creates
natural shape, structure and color of the fractured teeth. The
advantage of composite resin build up of fractured childrens
teeth is preservation of hard tissues. Achievement of
predictable and satisfactory results when restoring fractured
teeth of schoolchildren is carried out by creation and
following of systematic protocol.

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Address for correspondence:
Dr. Ani Beltcheva, PhD
Department of Pediatric Dentistry, Faculty of Dental Medicine, Medical
University, Plovdiv
-mail abeltcheva@yahoo.com;
http://www.journal-imab-bg.org
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